Revenge of the Clinical Informaticists

This spring, the New York Times published an article on the rise of clinical informatics degree programs and of the clinical informaticist role in healthcare, under the title, “Connecting the Dots of Medicine and Data. Of course, the Times is known for its careful, detailed reporting on topics that go beyond the most immediate news headlines. Even so, I was surprised and delighted to see this 809-word article on a topic that few outside our industry are yet aware of.

Reporter Christine Larson focused in on Russ Cucina, M.D., a practicing internal medicine specialist at UCSFMedicalCenter in San Francisco who spends half of his time at that teaching hospital practicing, and half of his time as a clinical informaticist. The article explains what Dr. Cucina does, and why, and also interviews a few other clinical informaticists who work for a vendor and for a consulting firm, respectively (and she even explains the separate subspecies of non-physician clinical informaticists, the nurse and pharmacist clinical informaticists); and talks to an accreditation official who discusses the rise of advanced-degree clinical informatics programs and what they’re about. Ms. Larson also interviewed the chairman of the department of medical informatics and clinical epidemiology at Oregon Health and ScienceUniversity, and the president and CEO of AMIA.

And, rather than presenting Dr. Cucina and his colleagues as strange aberrations of an opaque industry, the reporter tried to sketch a portrait of a key role in the emerging new healthcare, one that I personally believe will be critical to transforming our overall healthcare system. I particularly liked Dr. Cucina’s quote, “I’m the glue between the I.T. enterprise and the clinical leadership… Because I have the vocabulary of both sides, I can serve as a translator between them.” In other words, heroes of patient care quality improvement, not nerds with scotch-taped eyeglasses. (YAY!)

The good news in all this, of course, is that laypeople are increasingly being given more substantive glimpses of what the healthcare industry is all about, and that can only be for the good, even if it inevitably brings increased scrutiny to ever-deeper nooks and crannies within healthcare.

Personally, I hope more and more healthcare consumers and average (if educated) people become aware of the Russ Cucinas of healthcare: this is how our society will become better informed, and hopefully, better able to make good choices about healthcare, as consumers, as voters, and as citizens. And, in the process, it might even attract some more young people (who are desperately needed) with the talent and the interest to assume this extremely worthy role inside today’s—and tomorrow’s—patient care organizations.

Comments

Joe,Thank you for your very thoughtful and wise comments. I agree. We need far more comprehensive and sophisticated linkages between and among human beings and elements of processes for all this to work. I'm just heartened that we as a healthcare system are beginning down the right path!

I wrote on this same topic yesterday, albeit with a slightly different bent. Like you, I see two distinct groups who do not play well in the same sandbox—clinical and IT. Having one group go to the other's summer camp to pick up a few skills is not the same as pulling a few costly and hairy projects from the bowels of project hell any more than it would be to have an IT executive take an EMT course and then assume that person was qualified to perform surgery—this one time at band camp...

Before I get up on my stool and knock myself off, I know CMIOs and CIOs who have made HIT and EHR very successful. To them I ask, do not rake me across the Twitter coals as I try to make a point.

There's knowledge, and then there's qualified. Doctors do four years of medical school, they intern, and if they specialize, they throw in a few more years before they become the in-charge. Years of training and practice before the doctor is allowed to run the show. Why? Because what they are about to undertake requires practice, tutelage, and expertise. Most of the actual learning occurs outside the classroom.

There are those—not Mr. Hagland—who suggest that the skills needed to manage successfully something as foreboding as full-blown EHR can be picked up at IT Camp. They do a disservice to seasoned IT professionals.

Most large IT projects fail. I believe large EHR projects will fail at an even higher rate. Most clinical procedures do not fail, even the risky ones.

What's the spin line from this discussion?

· Rule 1—large EHR projects will fail at an alarming rate· Rule 2—sending a doctor to band camp probably won't change rule one

Don't believe me? Ask friends in other industries how their implementation of an ERP or manufacturing system went. There are consulting firms who make a bundle doing disaster recovery work on failed IT projects. They circle the halls like turkey vultures waiting for CIO or project manager carrion.

Back to Rule 1 for a moment. How can I state that with such assurance? Never before in the history of before—I know that's not a proper phrase—has any single industry attempted to use IT to:

· impart such radical charge (patients, doctors, employees)· impart it on a national basis· hit moving and poorly defined targets—interoperability, meaningful use, certification· take guidance from nobody—there is no EHR decider· implement a solution from amongst hundreds of vendors· implement a solution with no standards· move from an industry at 0.2 to 2.0 business practices· concurrently reform the entire industry

Just what should a CMIO be able to do? What are the standards for a CMIO? To me, they vary widely. Is a CMIO considered an officer in the same sense as the other "O's" in the organization, or is it simply a naming convention? The answer to that question probably depends on the provider.

Here's how I think it should work—I realize nobody has asked for my opinion, but this way I'll at least provide good fodder for those who are so bold as to put their disagreement in writing.

I love the concept of the CMIO and think it is essential to move the provider's organization from the 0.2 model to the 2.0 model. Same with the CIO. However, getting them to pool their efforts on something like EHR is likely to fail as soon as one is placed in a position of authority over the other. It's sort of like getting the Americans and French to like one another.

I liken the CMIO's value-add to that of the person providing the color commentary on ESPN—it adds meaning and relevancy. The CMIO owns and answers a lot of the "what" and the CIO owns and answers a lot of the "How".Still unanswered are the "Why" and "When". A skill is needed that can state with assurance, "Follow me. Tomorrow we will do this because this is what needs to be done tomorrow." That skill comes from an experienced Project Management Officer, the PMO. It does not come from someone who "we think can handle the job." Nobody will respect that person's ability, and if they can't lead, yo can plan on doing the project over.

Mark,I agree. It's good to see the role emerging beyond one or two lonely people, per hospital, trying to stick things together that need to be.

The vision, however, needs two more elements: 1) the patient's needs, and 2) duct tape. I'll dispense with the later - glue and scotch-tape are how we got into this mess. It's a bigger problem than get the interfaces between systems in place and we're done.

The quick story on patient's needs is personal When my doc sends me my labs, they look like, well ... labs. Then, there's a hand written note at the bottom: cholesterol and liver tests are fine. Keep taking your meds.

Does she know what those meds are when she writes that? Often not. There's a trust thing going on. When I review my dads results that come the same way, do I know what combination of drugs he taking now? When my friends who are on coumadin get their call, are they looking at the same, crisp, up-to-date synopsis of relevant results, reviewed current meds, and measures of toxicities? Short answer. No.

The glue between the IT enterprise and the clinical leadership doesn't cut it. An executive working toward closing the inferential gap, so that people reliably get the care they want and need, enabled by the IT enterprise and clinical leadership? That's much, much better. (I've got to work duct tape into that!)

Clearly, we need a group of clinicians who can bridge between the IT administration and hospital finance crowd and the medical staff. What we need to avoid is a cadre of clinicians who are totally subverted to the dark side of administration, where they consistently decline to (1) tell the hospital side the truth about the medical IT world as it is working and (2) communicate back to the vendors about the good and the bad of their systems. Such a clinical specialist should have authority to tell everyone to slow down their projects, and make the existing ones work as well as possible. that also means telling vendors and administration to have their products appropriately upgraded over time. example of failure of this latter type: our hospital web paging system is around 12 years old and has not seen any upgrades. it has flaws that have accrued as clinical needs have changed. we need someone to go to bat to get the work done.

the temptation in a clinical IT environment is to expect everyone to say that everything is just ducky. in my personal experience with three major clinical systems and two for billing/scheduling, the truth is usually otherwise. the clinical IT doctor must be able to discern the usual physician griping from an expression of frustration at major flaws and failure.

finally, that clinician can never be allowed to ignore the medical staff when complaints come in, and requests and suggestions should be taken seriously and courteously. having been dissed in my time by an IT doc, the political savvy of the position is clearly very important.